肝脏疾病本科彭涛2011 ppt课件.ppt
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1、个人简历,Liver Diseases 肝脏疾病,彭涛 教授、博士生导师 外科学教研室 (肝胆血管外科) 2011-10-17,3,肝脏解剖生理概要-1,The liver lies in the right upper quadrant of the abdomen, under the protective rib cage, beneath the diaphragm and connected to the digestive tract by means of portal vein and biliary drainage system. Gilssons capsule, bar
2、e area, falciform lig., coronary lig., gastrohepatic lig., hepatoduodenal lig. foramen,1: liver; 2: rib cage; 3: spine; 4: pelvis,4,肝脏解剖生理概要-2,The American (lobar) system & the French (Couinaud segmental) system.,5,肝脏解剖生理概要-3,6,肝脏解剖生理概要4 -Cauinaud segmentation,7,肝脏解剖生理概要5 -left hepatic vein,8,肝脏解剖生理
3、概要6 -middle hepatic vein,9,肝脏解剖生理概要7 - hepatic vein & portal vein,10,肝脏解剖生理概要8 - portal vein plane,11,“精准肝脏外科时代” 保留肝中静脉的左半肝切除,12,“精准肝脏外科时代” 保留肝右静脉的右后叶肝切除,13,双重血供 (75% via 门静脉 & 25% via 肝动脉) 肝动脉携氧量占50 门静脉两端是毛细血管网,无功能性静脉瓣 门静脉不可结扎或切断 肝脏血流阻断时间15-20min,肝脏解剖生理概要9 - circulation,14,代谢: bilirubin, carbohydra
4、te, lipid, protein, vitamin, drugs ICG15min渚留率,肝脏解剖生理概要10,Hepatic Trauma 肝脏创伤,16,Hepatic trauma -Classification and characteristics,Penetrating hepatic-trauma Due to bullets, knives etc.less devitalization of liver parenchyma Due to missiles shatter massive parenchyma Blunt hepatic-trauma Due to dir
5、ect blow to the upper abdomen or lower right rib cage, or sudden deceleration. Might be explosive bursting wounds or linear lacerations. The posterior superior segment (SVII) is mostly vulnerable due to its location. Damage to the hepatic veins is catastrophic and difficult to expose during explorat
6、ion. (The staging system is for your reference only, but pls pay attention to by what index it score the damage),17,Symptoms and signs: hypovolemic shock (hypotension, decreased urinary output, low central venous pressure) Laboratory findings: no detectable anemia due to rapid blood loss. Leukocytos
7、is is common. Imaging findings: CT scan is prior to other techniques among stable patients. It can estimate the type and severity of the injury, which is useful information for both triaging and exploration if necessary. Sonography is of limited value; angiography is diagnostic in hemobilia.,Hepatic
8、 trauma -Clinical findings,18,Hepatic trauma -imaging findings,19,Hepatic trauma -imaging findings,Hydrops at the adrenal gland,Hepatic trauma with fracture of left rib,20,Hepatic trauma -Treatment,In a review of 1842 liver injuries from 1975-1999 in USA, nonsurgical therapy is used in more than 80%
9、 of blunt injuries. The death rates from both blunt and penetrating trauma have improved significantly due to decreased death from hemorrhage.,J. David Richardson, et al. ANNALS OF SURGERY, 232( 3): 324330.,21,Hepatic trauma -Treatment Nonoperative management for patients with stable minor injuries,
10、Contained subcapsular or intrahepatic hemotoma, Unilobar fracture Absence of devitalized liver Minimal intraperitoneal blood Absence of injuries to other intra-abdominal organs. However, repeatedly examination should be carried out during the observation !,22,Hepatic trauma -Treatment Exploration fo
11、r patients with active bleeding or a major injury,Techniques include: Drainage for wounds without hemorrhage Suture for bleeding vessels Massive injury may require lobectomy Subcapsular hematomas requie thoroughly exploration. Temporary clamping the inflow vessels in the hilum helps ligating bleedin
12、g vessels. Ancillary bypass, packing or absorbable gauze mesh may help in some cases.,23,Hepatic trauma -Complications and prognosis,Rebleeding Subhepatic sepsis Hemobilia-selective angiography and embolization Stress ulcersH2 receptor antagonists (Cimetidine, Ranitidine, Omeprazole etc) Mortalityde
13、pends on the type and severity of injuries.,24,肝脏肿瘤的分类,良性肿瘤:肝腺瘤,肝血管瘤 原发性肝癌 恶性肿瘤: 继发性肝癌:转移性,原发性肝癌 Primary Liver Cancer ,26,原发性肝癌,组织病理类型: 肝细胞癌: Hepatocellular carcinoma (HCC);约91%; 胆管细胞癌: Cholangiocellular carcinoma (cholangiocarcinoma); 7%8%; 混合细胞型肝癌: Mixed form (hepatocholangioma). 1%2%,27,ICC即使病理诊断
14、也要小心谨慎,28,背景 (肝细胞癌,HCC),西方国家少见, 有地理分布特异性(非洲撒哈拉地区、东南亚、日本、太平洋岛国、希腊、意大利) 曾被认为是“癌肿之王”、“不可治愈” 临床症状隐匿,发现多已晚期 近2030年诊断和治疗获得了长足的进步 根治性切除后5-yrs存活率 3070%.,29,背景 - 病因一览,病毒性肝炎 (HBV, HCV et al.) 真菌毒素 (黄曲霉毒素aflatoxins) 饮水污染 (池塘或沟渠水) Other causes 遗传 酗酒 Alpha-antitrypsin deficiency Hemochromatosis Plant alkaloid Or
15、al contraceptives Androgens Vinyl chloride Trace elements(?): Cu, Zn, Ni and Co Parasites: Clonorchis sinensis,30,1/100,000 5/100,000,背景 流行病学,全球发病率在上升 发病有地理特征 非洲: 164.6/100 000 (莫桑比克) 美国:标化发病率 1-7/100 000 /年 男性多于女性:49 :1(1:1 in group without preexistent liver disease) 移民美国的东方人发病率6倍高于白人,20/100,000 40
16、/100,000,NPC HCC,31,中国是HCC高发地区,Global Cancer Statistics, 2002. CA Cancer J Clin 2005;55;74-108,2002年全球新发病例 626,162 中国病例占55,约344,000 男性高发于女性 (2.67 : 1),32,背景 中国流行病学,1995 全国肿瘤普查 死亡率 20.40/100,000 29.07/100 000 (男) 11.23/100,000 (女) 自1990s, NO 2. 肿瘤杀手 (城市次于肺癌,农村次于胃癌;15 34岁国人的头号肿瘤杀手) 中国的地理分布特征:东南沿海 高发区(
17、 30/100 000) :广西扶绥、江苏启东、浙江舟山、福建同安,33,病理要点,大体病理类型: 巨块型: 结节型: 弥漫型: 分化程度: 包膜:(+)预后相对较好 (Fibrolamellar hepatoma) 转移: 淋巴结 (hilar, celiac) 肺 腹腔 门静脉、肝静脉,34,早期肝癌和小肝癌的概念,早期肝癌是指没有临床症状和体征的肝癌,亦即亚临床肝癌。 微小肝癌:2.0cm 小肝癌:2.0cm 10.0cm,35,Hepatocellular carcinoma, liver, gross,A 2.0 cm HCC arising in a chronic viral h
18、epatitis; the tumor, which had a predominant acinar architecture, produced abundant bile.,36,Hepatocellular carcinoma, liver, gross,Nodule of hepatocellular carcinoma in chronic hepatitis C; the pale golden yellow color is common.,37,Hepatocellular carcinoma, liver, gross,The neoplasm is large and b
19、ulky and has a greenish cast because it contains bile. To the right of the main mass are smaller satellite nodules.,The satellite nodules of this hepatocellular carcinoma represent either intrahepatic spread of the tumor or multicentric origin of the tumor.,38,Hepatocellular carcinoma, liver, gross,
20、Another hepatocellular carcinoma with a greenish yellow hue. Such masses may also focally obstruct the biliary tract and lead to an elevated alkaline phosphatase,39,HCC (fibrolamellar carcinoma ), gross,Well demarcated fibrolamellar carcinoma with central scar; the surrounding liver is normal.,Coars
21、e lamellar fibrosis is characteristic histologically; note the pale body in the large eosinophilic malignant hepatocyte (X40).,40,Hepatocellular carcinoma, liver, microscopic,The malignant cells of this HCC (seen mostly on the right) are well differentiated and interdigitate with normal, larger hepa
22、tocytes (seen mostly at the left ),This HCC is composed of liver cords that are much wider than the normal liver plate that is two cells thick. There is no discernable normal lobular architecture, though vascular structures are present.,41,临床表现 症状、体征,早期无明显症状:即亚临床肝癌(无症状和体征) 肝区疼痛:常见的首发症状,持续性钝痛、刺痛、胀痛;可
23、伴牵涉痛 肝肿大:中、晚期肝癌常见 消化道症状:腹胀、食欲减退、恶心呕吐、腹泻、出血 全身症状:乏力、消瘦、低热 晚期肝癌症状:贫血、黄疸、腹水、浮肿、恶液质 癌肿转移部位的相应症状:肺、骨、脑 伴癌综合症:低血糖症、红细胞增多症、女性男性化,42,临床表现 实验室检查,Serum bilirubin: nonspecific Alkaline phosphatase: nonspecific HBsAg, HCV-Ab: nonspecific AFP (甲胎蛋白): 7080% HCCs升高; 假阳性 见于慢活肝、急性肝炎、生殖腺肿瘤、妊娠. 术后复发监测(半衰期约67天). 正常上限 2
24、0ng/ml; 200ng/ml 拟诊 HCC.,43,临床表现 影像学,要点:大小、数量、位置、毗邻、门静脉癌栓、肝硬化、门静脉高压 X线:肝影增大、膈肌升高、胃横结肠受压 超声:适于筛查;分辨率2cm CT (平扫+增强) :分辨率 12cm;有助于鉴别血管瘤 MRI:分辨率 12cm;有助于鉴别血管瘤. 选择性腹腔动脉或肝动脉造影:分辨率 12cm HCC较相邻肝实质血管丰富 胆管细胞癌相对乏血供 血管瘤有特征性的血管池动态影像 静脉期可显示门静脉占位 CT碘油造影可显示微小HCC.,44,HCC-Imaging findings (DSA),45,HCC-Imaging finding
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